Friday, June 23, 2017

New “Locality Rule”, New Problem

Let’s Review

If you’ve followed this space or have been connected to the EMS billing world for a fair amount of time, you should recognize the impact of the phrases “nearest hospital” and “closest appropriate facility.”
New “Locality Rule”, New Problem
Center for Medicare and Medicaid Services (CMS) rules for Medicare clearly stipulate that Medicare will only pay ambulance ground miles while the patient is loaded in the ambulance for transport and only the amount of miles that it takes to transport he patient to the nearest and closest appropriate facility.

However, the Medicare Administrative Contractors (MACs) have been allowed to process claims using what we refer to as the “locality rule”.

The “locality rule” allows for when patients normally seek medical attention at a few regional hospitals on a regular basis. The theory is the patient should be able to “shop around” for care and have a reasonable choice as a healthcare consumer to seek medical attention for the best value and even, in some cases, price.

So, if Hospital A is a bit more distant in miles than Hospital B, CMS/Medicare has approved payment for the additional miles to Hospital A because patients in that general geographical region seek medical attention at either facility on a regular basis

What’s Changing?

This week, CMS released Transmittal 236 (Change Request 10110). This communication from CMS announced that beginning on September 18, 2017, the MACs will have the discretion to define “locality” in the various healthcare service areas that comprise the MACs jurisdictional territory (typically several contiguous States.)

We envision that the ambulance industry can expect the MACs to define many of these areas and the end result may be a deviation from how claims are currently processed.

For example, you may have long ago determined that your patient population regularly seeks treatment at any one of four facilities and have been billing full loaded mile totals and receiving Medicare reimbursement for those total miles.

Come September 18th, the MAC for your jurisdiction will have the ability to issue a communication that defines that only two of the four hospitals in your area will be considered to fit the “locality rule.” Now, instead of billing full loaded mileage totals when you transport a patient to one of the two that are no longer determined to be in “locality”, your billing office will be limited to billing the miles equal to the closest appropriate facility and the additional miles beyond that total will be required to be billed to the patient for out-of-pocket payment.

Thinking Ahead…

We brainstormed just some of the results of this change may look like and here are our thoughts…
  • Cash flow changes- your EMS agency is used to a certain number of miles paid nice and neatly from Medicare and now a portion of those miles will not be immediately reimbursed.
  • Patient liability portions will increase, causing a potential undue hardship for patients which will delay their satisfying the amount due to your EMS agency for the transport.
  • Patient frustration will probably increase and we fear that instead of the blame going to CMS/Medicare it will be deflected to the EMS agency. Rest assured no one is going to understand this change or even be aware of it.

What can we do?


Run the numbers. Think about those facilities that potentially may fall outside of a newly and narrowly MAC-defined “locality” and project what the potential dollar hit to your organization may be and begin to have an alternative budget ready to go post-September 18.

Additionally, think about and begin preparing some public education and communication on the matter. Be prepared for how you and your staff and your billing office will communicate this change to patients so they understand why they now are receiving a bill for the same transport that, two months ago, Medicare paid for the entire trip.

Educate your staff, too. Be sure they understand what’s coming. Our friends at Page, Wolfberg and Worth mentioned that EMS agencies may wish to increase the use of the Advance Beneficiary Notice of Non-Coverage (ABN) to inform your patients, up front, that they will have financial liability beyond what Medicare pays. Be sure the staff understands how to present the and explain the ABN in the field.

Finally, educate the facilities you serve as they may be able to help you spread the word about what may be changing too.

The Ambulance Billing Services blog is brought to you as a service by Enhanced Management Services, Inc.  Enhanced Management Services, Inc. is a full-service, all-EMS third-party billing contractor with Fire/EMS clients located across the United States.  For more information about how Enhanced can benefit your EMS agency, please visit our website at and click on the “Get Started” button on any landing page.

Friday, June 16, 2017

The Do’s and Don’t’s of PCS Signatures

Signature Focus

The Physician Certification Statement (PCS), required by Medicare for all non-emergency transports, can confuse even the seasoned ambulance administrator and billing office. While the document itself can be confusing, determining the person who can properly sign can be an even more confusing scenario.


The Center for Medicare and Medicaid Services (CMS) requires that a PCS be obtained and maintained on file for every non-emergency, routine transport. The difference between the use of the PCS for repetitives versus non-repetitives lies in when the PCS is obtained (prior to transport for repetitives) and who can sign (physicians must sign repetitives).


PCS’s for scheduled/repetitive transports can only be signed by a physician. Period!

M.D.’s or D.O.’s are the only health care professionals that can sign a PCS pertaining to a patient who is transported at least three times over a ten-day period or once per week for three consecutive weeks.


PCS’s for unscheduled/non-repetitive transports can be signed by the following health care professionals so long as that health care professional signing has first-hand knowledge of the patient’s overall condition. The person signing the PCS, other than a physician (MD or DO) can be a Registered Nurse (RN), Certified Nurse Specialist (CNS), Physician’s Assistant (PA), Nurse Practitioner (NP) or a “Discharge Planner.”

“Discharge Planner” Confusion

We often field questions about “Discharge Planners.” One of the common confusions surrounding PCS’s is how to define these persons.

A “Discharge Planner” is someone, typically in the institutional setting, that actually wears that title defining his/her place in the system and arranging for patient ambulance transports. For example, while the regulations do not allow for Licensed Practical Nurses (LPN’s) to sign a PCS, it is possible for an LPN that occupies the position of a hospital Discharge Planner to sign the PCS but not in the capacity of the scope of the LPN but rather within his/her role as a titled Discharge Planner. The same scenario would apply to a Social Worker.

Said another way, the LPN floor nurse who does not serve in the specific role as a Discharge Planner would not be acceptable to sign. However the LPN occupying a Discharge Planner job function would be an acceptable signor.

Therefore, “Suzy Smith, LPN, Discharge Planner” would be an acceptable signature for the PCS as long as that person’s title and job function is well defined and there is a proven history of that person occupying a specific “Discharge Planner” role. Likewise it is extremely important that the actual words “Discharge Planner” be typed or handwritten in proximity to the signature. The same would apply to a social worker or similar person that performs “Discharge Planner” functions as part of his/her job functions.


The health care professional’s signature must be handwritten, however the rules do allow for an electronic signature that is a computer produced handwritten signature. The acceptable electronic signature would be one where the health care professional signs using an electronic pen on a computer signature pad that generates the signature facsimile onto the PCS, instead of the doctor signing using an ink pen on paper.


It is important that even the actual signature be vetted out by EMS personnel as proper or improper.

Signatures must be legible to be accepted. If a signature is illegible (viewing the signature does not yield the identity of the person signing, just by looking at it), then it is important that the name is always printed adjacent to the signature. The best way to cover this is to have the signing health care professional always print his/her name adjacent to any signature, legible or illegible, and have that person include his/her credentials, as well.

The health professional signing must sign using his/her full first and last name.


CMS rules do allow for what’s called “Signature Attestation” for those health care professionals that habitually sign with illegible signatures. However, this means that a master signature attestation statement or log must be maintained by the ambulance service showing the health care professional names with signatures on the page in order that they can be compared to an actual signature at some later time to prove the identity of the persons signing. This is a lot of work and requires continual record-keeping, not to mention the requirement of keeping such attestation sheets up-to-date to include both incoming and outgoing health care professionals.

Signature Dating

Finally, for this discussion it is important that the health care professional signing the PCS always date his/her signature. This is a must! The date that the person signs the PCS should be included adjacent to the signature and that area is separate from the date of service/transport listed at the top of the PCS document, as is the case for the common PCS documents that are widely used in the ambulance industry today.

The Ambulance Billing Services blog is brought to you as a service by Enhanced Management Services, Inc. Enhanced Management Services, Inc. is a full-service, all-EMS third-party billing contractor with Fire/EMS clients located across the United States. For more information about how Enhanced can benefit your EMS agency, please visit our website at and click on the “Get Started” button on any landing page.

Friday, June 9, 2017

Compliance by Accident…is an Accident Waiting to Happen!

Out of Sight…Out of Mind

How many of you reading this blog, right now, have a compliance plan located somewhere in your office or somewhere in the station?

Compliance by Accident…is an Accident Waiting to Happen!
You know what I mean, that big binder book with a lot of paper, plenty of words that seemingly took forever back in 2000-something (or maybe even before) to put together but now has a layer of dust on top of it about 3 inches thick.

It’s that book that when someone asks you if you have a “Compliance Plan” you answer definitively with even a bit of chest pumping… “YES!”

But all the while you are proud of the fact that you have a binder somewhere with the word compliance in it or on it…you are really thinking… Do I remember what’s in it?

A Plan Without Action?

And…this is where the problem is.

A quick look at the dictionary yields this definition for the word “plan”…

A detailed proposal for doing or achieving something

Note the action words…doing and achieving.

We’ve never known of a compliance plan that periodically leaps from the shelf down onto the floor and moves fluidly about your organization magically mandating that you and your staff follow the plan.

A plan without action….well…is just a plan and will achieve nothing!

How Long Has it Been?

Answer this question, right now…not later…now. 


How long has it been since I last read over my agency’s compliance plan?

If your answer contains the word years…shame on you.

If you answer contains the word months…shame on you.

Worse yet, it’s not that you’ve read the plan but have you acted on the plan? If it has been years or months since you have dusted off the plan and have put any one or all of the provisions of the plan into continuous action, then you and your agency are ripe to fail and someone will take note.

Someone with a badge maybe? Someone with authority? Someone that will definitely cause you grief.

We will be audited!

Repeat this phrase out loud so you hear yourself say it…

We will be audited!

Now repeat it one more time.

Did you hear yourself?

Scary? Give you chills? If not, it should!

There was a time in this industry when a Medicare or Medicaid audit was conducted against the guy that you read about who really colored outside the lines. You could hear the rattle of the handcuffs. Jail time was imminent.

That’s not the case anymore.

For every dollar that the Feds are spending on audit activity, they are recovering around eight dollars in return. That’s not a bad return on investment!

And…with the exception of those who set out to purposely defraud the government, the dollars are being recovered from every day “normal” EMS agencies who probably have that dusty binder labeled sitting on a shelf, unimplemented.

You go along for a long time and think you’re okay and then BAM! Out of nowhere you find out that you should have paid more attention to “The Plan.”

“Radical Compliance Terrorists”

Compliance with the billing rules and regulations (of course, others too…but this is a EMS billing blog) that tell us how to do things MUST be an everyday occurrence.

The SOG/SOP’s that you follow must include compliance measures. You must audit internally for issues. Your billing office must audit internally for issues. Of course, we recommend that you contract with a billing agency that practices compliance religiously. Your billing office must be radical compliance terrorists especially with regard to the Patient Care Reporting and the documentation, signatures, PCS documents straight on through to the coding and billing of the claim.

If that doesn’t sit well with the street staff, well then it’s time they got onboard and understand why it’s so important to their wellbeing just as much as the billing office staff.

How long has it been since you read over the plan itself to be sure that all parts of it are even relevant? Things change. The plan must change too. And…do you have a way of measuring the plan’s effectiveness?

Today’s Action Item

Today we give you an action item.


Get up from your chair. Finish reading this blog. 

And…wait for it…


It’s time to make that dusty plan come to life!

Review. Measure. Implement. Act. 

And…then…repeat it all tomorrow and the next day and the next day…

The Ambulance Billing Services blog is brought to you as a service by Enhanced Management Services, Inc. Enhanced Management Services, Inc. is a full-service, all-EMS third-party billing contractor with Fire/EMS clients located across the United States. For more information about how Enhanced can benefit your EMS agency, please visit our website at and click on the “Get Started” button on any landing page.

Friday, June 2, 2017

Why is S. 967 So Important to the Ambulance Industry? Part IV

S.967- Part IV

Today we land Part IV of our blog posts dedicated to helping us all understand the importance of Senate Bill 967 entitled the “Medicare Ambulance Access, Fraud Prevention and Reform Act of 2017.”

Why is S. 967 So Important to the Ambulance Industry? Part IV
In that opening post, we explained that the bill addresses four areas to benefit EMS in America.
  • Reform to the Medicare ambulance fee schedule
  • Prior Authorization for ambulance transports of ESRD beneficiaries
  • Requiring providers of services and ambulance service providers to submit cost data and other information with respect to ambulance services
  • Treatment of ambulance service providers

In Week One we focused on how the bill proposes to permanently incorporate the add-on bonus payments to the Medicare ambulance fee schedule. Week Two’s discussion centered on the proposal to add a Prior Authorization process for pre-approval of all ambulance transports provided to ESRD beneficiaries to and from dialysis treatments.

Last week, we focused on the “bitter pill” in this proposed legislation, as we explained our view of the provision that will request that we all submit costs data and information about our day-to-day operations.

Now, to bring this all to a landing; we’ll take a look at the move from being an ambulance supplier to a provider of service


Since Medicare began paying for ambulance transports, the Feds have considered us a supplier of services.

CMS defines a supplier as…
“A company, person, or agency that’s been certified by Medicare to give you a medical item or service except when you’re an inpatient in a hospital or skilled nursing facility.” ( Glossary of Terms)
In contrast, a Medicare provider is defined as…
“A health care provider (like a home health agency, hospital, nursing home or dialysis facility) that’s been approved by Medicare.”

What’s the difference?

The real difference that makes this provision so important is that the federal Medicare program has a very different view of suppliers versus providers aside from the bland definitions.

A provider is one who cares for patients by providing treatment to patients.

Suppliers are those who furnish goods and services used in patient care and treatment.
By moving us from a furnisher of goods and services to the realm of someone or, in the case of an ambulance service, to a group a people who provide treatment; it opens the door for EMS to be paid by Medicare (and then hopefully by extension to other payers- Medicaid, commercial insurers, etc.) for providing treatment possibly without providing transportation.

The End Goal

The end goal of all of this is to open the door for all of us to be reimbursed in ways that we have not heretofore been considered for reimbursement.

Can this provision open the door for reimbursement for Mobile Integrated Health Care (MIHC/Community Paramedicine) covering wellness checks and services such as preventative care in the field? Will we now see reimbursement begin to flow when we treat a diabetic patient and the patient chooses to not be transported? Will we finally be recognized for the individual services we provide and ultimately shed the title “ambulance driver” from patients’ vocabularies?

Don’t miss the significance of this change. It’s huge!

Imagine removing the stress from what we do as we wrestle with protocols that sometimes encourage us to not transport versus receiving reimbursement to pay for our services if we do transport, as is the current case.


Of course, Congress and the bureaucracy that supports Medicare also recognizes that, as many experts have demonstrated, such a move may just save the Medicare system precious dollars. Potentially, the move will have an effect on fraud and abuse where unscrupulous ambulance suppliers nudge their staff toward transporting to help pay the bills even when the scenario may not warrant transportation.

Potentially, we can treat a patient and feel more comfortable about advising against transport and still get paid for the treatment we have provided minus an actual transport.

Plus, by being eligible to be reimbursed for treatments in the field the system will support follow-up with chronically ill patients to lessen their need for emergency services thus relieving a growing burden on emergency services through preventative measures- taking the strain and the cost off, not only pre-hospital providers, but also stressed emergency departments.

The potential

S.967 has the potential to change our EMS world in the United States.

Now you know what it is, so it’s time to get out there and lobby our Federal lawmakers to pass this measure. You have a voice…time to make yourself known!

The Ambulance Billing Services blog is brought to you as a service by Enhanced Management Services, Inc. Enhanced Management Services, Inc. is a full-service, all-EMS third-party billing contractor with Fire/EMS clients located across the United States. For more information about how Enhanced can benefit your EMS agency, please visit our website at and click on the “Get Started” button on any landing page.